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Smyth H, Gorey S, O'Keeffe H, Beirne J, Kelly S, Clifford C, Kerr H, Mulroy M, Ahern T. Generalist vs specialist acute medical admissions - What is the impact of moving towards acute medical subspecialty admissions on efficacy of care provision? Eur J Intern Med 2022; 98:47-52. [PMID: 34953654 DOI: 10.1016/j.ejim.2021.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The discussion surrounding generalist versus specialist acute medical admissions continues to stimulate debate and patients with certain conditions benefit from specialist care. AIM To determine whether a specialty medical admission program would reduce inpatient length of stay (LOS), mortality and readmission rates. DESIGN/METHODS A prospective cohort study of inpatients admitted under a general internal medicine (GIM) service before and after introduction of a specialty-directing programme. We hypothesized that early transfer of patient care to a specialty suited to their presenting complaint would reduce LOS and a specialty-directing early redistribution of care programme was introduced. Seven of the ten clinical teams participating in the GIM roster adopted the programme. On the morning following a specialty-directing team being on call for all new GIM admissions during a 24-hour period, specialty-directing teams were allocated one patient appropriate to their specialty. RESULTS 5,144 patient-care episodes were analysed over the two-year study period. LOS increased by greater than 15%, one year after introducing the specialty-directing programme (8.5±8.4 vs 7.3±7.5 days, p < 0.001). LOS did not differ between teams that participated and those who did not (8.4±8.1 vs 8.1±7.9 days, p = 0.298). No differences were found in the proportion of patients who were discharged home, died while an inpatient or re-admitted within 30 days of discharge. The proportion of patients aged greater than 80 years increased significantly also - from 24.7% in 2017 to 27.9% in 2019(p == 0.009). CONCLUSION Widespread adoption of specialist care may not be beneficial for all medical inpatients and physicians should continue to undergo dual specialist and GIM training.
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Affiliation(s)
- Hannah Smyth
- Specialist Registrar in Geriatric Medicine and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland.
| | - Sarah Gorey
- Specialist Registrar in Geriatric Medicine and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Hannah O'Keeffe
- Specialist Registrar in Nephrology and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Joanna Beirne
- Senior House Officer in General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Shaunna Kelly
- Senior House Officer in General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Cathal Clifford
- Specialist Registrar in Gastroenterology and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Hilary Kerr
- Senior House Officer in General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Martin Mulroy
- Consultant Physician in Geriatric Medicine and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
| | - Tomás Ahern
- Consultant Physician in Endocrinology and General Internal Medicine. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland
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Chou PL, Chiang IH, Lin CW, Wang HH, Wang HK, Huang CH, Chang CS, Huang RY, Lin CY. Newly Diagnosed Type 2 Diabetes Care between Family Physicians, Endocrinologists, and Other Internists in Taiwan: A Retrospective Population-Based Cohort Study. J Pers Med 2022; 12:jpm12030461. [PMID: 35330461 PMCID: PMC8955527 DOI: 10.3390/jpm12030461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/04/2022] [Accepted: 03/10/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background: We aimed to determine whether physicians of different specialties perform differently in the monitoring, cost control, and prevention of acute outcomes in diabetes care. (2) Methods: Using data from the Health and Welfare Data Science Center, participants with newly diagnosed type 2 diabetes (n = 206,819) were classified into three cohorts based on their primary care physician during the first year of diagnosis: family medicine (FM), endocrinologist, and other internal medicine (IM). The three cohorts were matched in a pairwise manner (FM (n = 28,269) vs. IM (n = 28,269); FM (n = 23,407) vs. endocrinologist (n = 23,407); IM (n = 43,693) vs. endocrinologist (n = 43,693)) and evaluated for process indicators, expenditure on diabetes care, and incidence of acute complications (using subdistribution hazard ratio; sHR). (3) Results: Compared to the FM cohort, both the IM (sHR, 1.26; 95% CI, 1.08 to 1.47) and endocrinologist cohorts (sHR, 1.57; 95% CI, 1.38−1.78) had higher incidences of acute complications. The FM cohort incurred lower costs than the IM cohort (USD 487.41 vs. USD 507.67, p = 0.01) and expended less than half of the diabetes-related costs of the endocrinology cohort (USD 484.39 vs. USD 927.85, p < 0.001). (4) Conclusion: Family physicians may provide better care at a lower cost to newly diagnosed type 2 diabetes patients. Relatively higher costs incurred by other internists and endocrinologists in the process of diabetes care may be explained by the more frequent ordering of specialized tests.
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Affiliation(s)
- Pei-Lin Chou
- Department of Family and Community Medicine, E-Da Hospital, Kaohsiung 82445, Taiwan; (P.-L.C.); (I.-H.C.); (C.-W.L.); (C.-H.H.)
| | - I-Hui Chiang
- Department of Family and Community Medicine, E-Da Hospital, Kaohsiung 82445, Taiwan; (P.-L.C.); (I.-H.C.); (C.-W.L.); (C.-H.H.)
| | - Chi-Wei Lin
- Department of Family and Community Medicine, E-Da Hospital, Kaohsiung 82445, Taiwan; (P.-L.C.); (I.-H.C.); (C.-W.L.); (C.-H.H.)
- College of Medicine, I-Shou University, Kaohsiung 82445, Taiwan; (H.-H.W.); (H.-K.W.); (C.-S.C.)
| | - His-Hao Wang
- College of Medicine, I-Shou University, Kaohsiung 82445, Taiwan; (H.-H.W.); (H.-K.W.); (C.-S.C.)
- Division of Nephrology, Department of Internal Medicine, E-Da Hospital, Kaohsiung 82445, Taiwan
- Department of Medical Quality, E-Da Hospital, Kaohsiung 82445, Taiwan
| | - Hao-Kuang Wang
- College of Medicine, I-Shou University, Kaohsiung 82445, Taiwan; (H.-H.W.); (H.-K.W.); (C.-S.C.)
- Department of Neurosurgery, E-Da Hospital, Kaohsiung 82445, Taiwan
| | - Chi-Hsien Huang
- Department of Family and Community Medicine, E-Da Hospital, Kaohsiung 82445, Taiwan; (P.-L.C.); (I.-H.C.); (C.-W.L.); (C.-H.H.)
| | - Chao-Sung Chang
- College of Medicine, I-Shou University, Kaohsiung 82445, Taiwan; (H.-H.W.); (H.-K.W.); (C.-S.C.)
- Committee for Advanced Medical Technology, E-Da Hospital, Kaohsiung 82445, Taiwan
| | - Ru-Yi Huang
- Department of Family and Community Medicine, E-Da Hospital, Kaohsiung 82445, Taiwan; (P.-L.C.); (I.-H.C.); (C.-W.L.); (C.-H.H.)
- College of Medicine, I-Shou University, Kaohsiung 82445, Taiwan; (H.-H.W.); (H.-K.W.); (C.-S.C.)
- Correspondence: (R.-Y.H.); (C.-Y.L.)
| | - Chung-Ying Lin
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (R.-Y.H.); (C.-Y.L.)
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Li MC, Wang LY, Ko NY, Ko WC. The impact of physician subspeciality on the quality of diabetes care for people living with HIV. J Formos Med Assoc 2021; 120:2016-2022. [PMID: 34636727 DOI: 10.1016/j.jfma.2019.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/29/2019] [Accepted: 12/09/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Management of comorbidities of people living with HIV (PLHIV) involves different care models, including providing diabetes care and HIV care by the same infectious diseases physician (IDP) ("consolidated care") or providing diabetes care by the physicians other than IDP ("shared care"). The impact of diabetes care model on PLHIV with diabetes mellitus (DM) has not been well-evaluated. METHODS A nationwide cross-sectional sample in the Taiwan National Health Insurance Research Database was used to compare the performance rates of seven guideline-recommended tests provided by the different subspecialists. RESULTS Of 523 PLHIV with DM, there were 54.88% (n = 287) in the consolidated care group and 45.12% (n = 236) in the shared care group. More patients in the consolidated care group received the tests of lipid profile (92.33% vs. 79.24%), creatinine (Cr) (93.73% vs. 78.39%), and alanine transaminase (ALT) (91.99% vs. 75.42%), but fewer received urine protein test (35.54% vs. 51.69%) and fundoscopic examination (8.01% vs. 33.90%). The two groups did not differ in the performance rates of serum fasting glucose and HbA1c. After controlling for demographic factors and diabetic severity, the consolidated group was less likely to miss the serum tests of lipid profile (odds ratio [OR]: 0.30), Cr (OR: 0.19), and ALT (OR: 0.23), but more often missed urine protein test (OR: 1.56) and fundoscopic examination (OR: 4.97). CONCLUSION These findings suggest the need to focus on different process indicators of diabetes cares in different care models to enhance the diabetes care for PLHIV.
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Affiliation(s)
- Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Liang-Yi Wang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Nai-Ying Ko
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Liu CC, Chen KR, Chen HF, Huang SL, Chen CC, Lee MD, Ko MC, Li CY. Association of doctor specialty with diabetic patient risk of hospitalization due to diabetic ketoacidosis: a national population-based study in Taiwan. J Eval Clin Pract 2011; 17:150-5. [PMID: 20825533 DOI: 10.1111/j.1365-2753.2010.01414.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, and its risks can be largely reduced by adequate and high-quality ambulatory diabetic care. The aim of this study is to assess the risk and frequency of developing DKA in relation to the specialty of doctors who provide diabetes cares. METHODS In searching for possible episodes of hospitalization due to DKA (ICD-9-CM: 250.1), we used a prospective cohort design in which 500,867 diabetic patients identified in the 1997 National Health Insurance (NHI) ambulatory care data set of Taiwan were linked to the 1997-2006 NHI inpatient claims data. The study subjects were categorized into four groups according to doctor specialty. A logistic regression model was used to assess the risk and frequency of DKA admission in relation to doctor's specialty. RESULTS Compared with the patients routinely cared by endocrinologists, those not consistently cared by endocrinologists had significantly increased odds ratios (ORs) of DKA admission, ranging between 1.51 and 2.12. Moreover, the adjusted OR of the higher DKA admission frequency (≥ 0.133 times/person-year) for the patients not regularly cared by endocrinologists was also significantly increased, between 4.45 and 6.93. CONCLUSIONS Doctor specialty significantly influenced the risk and frequency of DKA admission in diabetes patients in Taiwan. Local health care administrators and policy makers should therefore consider promoting the quality of diabetes care provided by non-endocrinologists.
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Affiliation(s)
- Chih-Ching Liu
- Department of Nursing, Zhong-Xing Branch of Taipei City Hospital, Taipei, Taiwan
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Abstract
Using data from the National Ambulatory Medical Care Survey, logit models tested for trends in the probability that visits by adult diabetes patients to their primary care providers included recommended treatment measures, such as a prescription for an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-II receptor blocker (ARB), blood pressure measurement, and diet/nutrition or exercise counseling. Results indicated that the probability that visits included prescription of an ACE or ARB and blood pressure measurement increased significantly over the 1997-2005 period, while the probability that visits documented provision of exercise counseling rose since 2001.
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Wang JS, Lin SY, Sheu WHH, Lee IT, Tseng LN, Song YM. Effects of patient volume on quality of outpatient diabetes care. Diabetes Res Clin Pract 2009; 84:e27-9. [PMID: 19269708 DOI: 10.1016/j.diabres.2009.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 01/11/2009] [Accepted: 02/09/2009] [Indexed: 11/19/2022]
Abstract
In this study we aimed to evaluate the effects of practice size (patient volume) and diabetes caseload in outpatient services on the quality of diabetes care in a teaching hospital. We analyzed the medical records of 2038 diabetic patients treated at a medical center in central Taiwan between January and June 2007. Outpatient practice size (including diabetic and non-diabetic patients) per clinic decreased the odds of glycated hemoglobin (A1C) testing (13% less for every 10 increase in outpatient encounters; p<0.001), and the percentage of A1C values<7% (8% less for every 10 increase in outpatient encounters; p=0.03) in diabetic patients treated by non-endocrinologists. However, a higher caseload of patients with diabetes was associated with an increased lipid profile measurement (19% more for every 5 increase in diabetic patients; p<0.001). In diabetic patients treated by endocrinologists, a higher patient volume was associated with increased odds of low-density-lipoprotein cholesterol (LDL-C) levels<100mg/dl, although there was no effect on the measurement and values of A1C. In conclusion, our study demonstrated some evidence of patient volume-outcome relationship in the management of diabetes in different specialties. This finding can have some implications to the health care system and the referral policy.
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Affiliation(s)
- Jun-Sing Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
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